epidura tips and tricks

versatile_kat · Aug 8, 2007

Hello all you smart ones.... I could really use some tips.
I am in my OB rotation at present and my hardest thing is truly identifying interspinous spaces. An MDA told me today that some just have a knack for feeling them, others have to work at it....apparently I am the later...
I would greatly appreciate any help. I mean I can ID intercrestal line and a plumb line down from C7, but on the prego's with some posterior/inferior fluff above the crack, it is tough.
Muchos Grassy-ass.

I've always found that in my fluffier patients, if I go about 5 inches straight up from the crack, eureka! - you should take a step back and double check the desired insertion area before numbing them up and going in with the epidural needle. It also helps if they are as straight as possible, so have the L&D nurse help keep mom's position.

Find the hips and get started - if you have to, tell mom you'll be pushing pretty hard on her back in order to find the correct space and use your index finger's proximal interphalangeal joint to start at around T8 and go down slow.

Good luck!

dfk, RN, CRNA · Aug 10, 2007

Hello all you smart ones.... I could really use some tips.
I am in my OB rotation at present and my hardest thing is truly identifying interspinous spaces. An MDA told me today that some just have a knack for feeling them, others have to work at it....apparently I am the later...
I would greatly appreciate any help. I mean I can ID intercrestal line and a plumb line down from C7, but on the prego's with some posterior/inferior fluff above the crack, it is tough.
Muchos Grassy-ass.

i don't mean to be mean, but if you are having trouble identifying spaces, which is pretty much the easiest of the procedure, then you are going to have trouble for a while. especially with pregnant peeps. they are traditionally more easier than say obese non pregnant, in my experiences anyway.

take a look at a spine/pelvis skeleton, feel it, picture it, close your eyes and see it in the dark, so when you are actually doing the procedure, you will see that image in your mind. that might help you guide your insertion.

zrmorgan · Aug 10, 2007

I have almost every patient in sitting position. I use my thumb to feel the space...I do tell them I am going to push really hard. The crack trick works well if the person is symetrical....sitting straight....I use this in addition to other techniques mentioned. Sometimes obese people will be very round, and almost perfectly symmetrical. Sometimes obese people (or those with scoliosis) will have a crack off the midline. Make absolutely sure they are sitting strait with nothing under them...I have found all sorts of crap piled under laboring patients...towels, peripads, needle caps, husbands etc (the nurses may get ticked if they are leaking all over the linnens...but epidural accuracy is a lot more important than clean bedsheets). Also make sure that their hips / knees / legs are the same distance from the edge of the bed. Some of my instructors in school even went as far as making sure the bed was perpindicular to the wall....this may be over the top, but this guy was a total neat freak and was always the go to guy for difficult sticks. Do definately step about 5 yards back and look at the big picture (really big if they are obese) and check the symmetry.

Last, once you have looked at all your surface landmarks, and get all prepped, take note of what you are feeling with the local needle. I use a 27 g 1.25 and take note of where I run into os, and where the path of least resistance is. This trick also works well for older people with arthritic spines and spinals. Obviously you can do some damage even with a small needle and you dont want to be probing around excessively.

Good luck, don't get discouraged. If you are still having trouble consistently after a couple hundred, then you can admit to being a slow learner...this stuff is a challenge that is why you'll love it.

zrmorgan

catcolalex · Aug 18, 2007

all the above are great tips, but there will always be the one that no matter how hard you try or push, you will not be able to feel any spaces. in that case you will use the local needle to find the processes and then angle up. it is really simple as that. after the skin is numb you can angle the local needle up and down as high or as low as you need and if you are midline you will hit os somewhere. after you hit it, walk up or down it until you can insert the needle easily but not inject local that is the flavum and paydirt. make note of the angle and position and chase it with the epidural needle.

terrywickscrna · Aug 19, 2007

Good morning, I am currently doing labor analgesia at our hospital on a routine basis. There are a couple strategies that you may find helpful in addition to what you are currently doing. First of all, I do virtually all of my labor epidurals with the patient sitting. Second, I ask the patient to put their elbows on their knees, crossing their arms in front of them, and have them tip their chin forward onto their chest. Third, wet your gloved fingers with the same PVP you prepped with and do firm vertical (up and down) palpation with your first and second fingers at the intersection of the intercrestal line and the midline. The lubrication of the PVP allows your fingers to move over the skin with greater pressure, and you may feel the spinous processes slipping under your fingers. Finally, be patient and try not to palpate when the patient is having a contraction, their whole body is tensed and they really can't pay attention to what you are saying.

Good Luck. Terry